Book Review: Larissa Behrendt, Chris Cuneen and Terri Libesman, Indigenous Legal Relations in Australia (Oxford University Press, Melbourne 2009) 376pp

Indigenous Legal Relations in Australia is a welcome and refreshing addition to the current literature on Indigenous legal issues. Written by a team of highly qualified Indigenous and non-Indigenous academics who share a long term commitment to Indigenous legal and social justice issues, this book provides a clearly written and accessible introductory text for tertiary students and general readers alike who are seeking to gain a deeper understanding of the relationship between Indigenous Australians and the Anglo-Australian legal system.

New insights into appetite, inflammation and the use of fish oil in hemodialysis patients

Protein-energy wasting (PEW) is commonly seen in patients with chronic kidney disease (CKD). The condition is characterised by chronic, systemic low-grade inflammation which affects nutritional status by a variety of mechanisms including reducing appetite and food intake and increasing muscle catabolism. PEW is linked with co-morbidities such as cardiovascular disease, and is associated with lower quality of life, increased hospitalisations and a 6-fold increase in risk of death1. Significant gender differences have been found in the severity and effects of several markers of PEW. There have been limited studies testing the ability of anti-inflammatory agents or nutritional interventions to reduce the effects of PEW in dialysis patients. This thesis makes a significant contribution to the understanding of PEW in dialysis patients. It advances understanding of measurement techniques for two of the key components, appetite and inflammation, and explores the effect of fish oil, an anti-inflammatory agent, on markers of PEW in dialysis patients. The first part of the thesis consists of two methodological studies conducted using baseline data. The first study aims to validate retrospective ratings of hunger, desire to eat and fullness on visual analog scales (VAS) (paper and pen and electronic) as a new method of measuring appetite in dialysis patients. The second methodological study aims to assess the ability of a variety of methods available in routine practice to detect the presence of inflammation. The second part of the thesis aims to explore the effect of 12 weeks supplementation with 2g per day of Eicosapentaenoic Acid (EPA), a longchain fatty acid found in fish oil, on markers of PEW. A combination of biomarkers and psychomarkers of appetite and inflammation are the main outcomes being explored, with nutritional status, dietary intake and quality of life included as secondary outcomes. A lead in phase of 3 months prior to baseline was used so that each person acts as their own historical control. The study also examines whether there are gender differences in response to the treatment. Being an exploratory study, an important part of the work is to test the feasibility of the intervention, thus the level of adherence and factors associated with adherence are also presented. The studies were conducted at the hemodialysis unit of the Wesley Hospital. Participants met the following criteria: adult, stage 5 CKD on hemodialysis for at least 3 months, not expected to receive a transplant or switch to another dialysis modality during the study, absence of intellectual impairment or mental illness impairing ability to follow instructions or complete the intervention. A range of intermediate, clinical and patient-centred outcome measures were collected at baseline and 12 weeks. Inflammation was measured using five biomarkers: c-reactive protein (CRP), interleukin-6 (IL6), intercellular adhesion molecule (sICAM-1), vascular cell adhesion molecule (sVCAM-1) and white cell count (WCC). Subjective appetite was measured using the first question from the Appetite and Dietary Assessment (ADAT) tool and VAS for measurements of hunger, desire to eat and fullness. A novel feature of the study was the assessment of the appetite peptides leptin, ghrelin and peptide YY as biomarkers of appetite. Nutritional status/inflammation was assessed using the Malnutrition-Inflammation Score (MIS) and the Patient-Generated Subjective Global Assessment (PG-SGA). Dietary intake was measured using 3-day records. Quality of life was measured using the Kidney Disease Quality of Life Short Form version 1.3 (KDQOL-SF™ v1.3 © RAND University), which combines the Short-Form 36 (SF36) with a kidney-disease specific module2. A smaller range of these variables was available for analysis during the control phase (CRP, ADAT, dietary intake and nutritional status). Statistical analysis was carried out using SPSS version 14 (SPSS Inc, Chicago IL, USA). Analysis of the first part of the thesis involved descriptive and bivariate statistics, as well as Bland-Altman plots to assess agreement between methods, and sensitivity analysis/ROC curves to test the ability of methods to predict the presence of inflammation. The unadjusted (paired ttests) and adjusted (linear mixed model) change over time is presented for the main outcome variables of inflammation and appetite. Results are shown for the whole group followed by analyses according to gender and adherence to treatment. Due to the exploratory nature of the study, trends and clinical significance were considered as important as statistical significance. Twenty-eight patients (mean age 61±17y, 50% male, dialysis vintage 19.5 (4- 101) months) underwent baseline assessment. Seven out of 28 patients (25%) reported sub-optimal appetite (self-reported as fair, poor or very poor) despite all being well nourished (100% SGA A). Using the VAS, ratings of hunger, but not desire to eat or fullness, were significantly (p<0.05) associated with a range of relevant clinical variables including age (r=-0.376), comorbidities (r=-0.380) nutritional status (PG-SGA score, r=-0.451), inflammatory markers (CRP r=-0.383; sICAM-1 r=-0.387) and seven domains of quality of life. Patients expressed a preference for the paper and pen method of administering VAS. None of the tools (appetite, MIS, PG-SGA, albumin or iron) showed an acceptable ability to detect patients who are inflamed. It is recommended that CRP should be tested more frequently as a matter of course rather than seeking alternative methods of measuring inflammation. 27 patients completed the 12 week intervention. 20 patients were considered adherent based on changes in % plasma EPA, which rose from 1.3 (0.94)% to 5.2 (1.1)%, p<0.001, in this group. The major barriers to adherence were forgetting to take the tablets as well as their size. At 12 weeks, inflammatory markers remained steady apart from the white cell count which decreased (7.6(2.5) vs 7.0(2.2) x109/L, p=0.058) and sVCAM-1 which increased (1685(654) vs 2249(925) ng/mL, p=0.001). Subjective appetite using VAS increased (51mm to 57mm, +12%) and there was a trend towards reduction in peptide YY (660(31) vs 600(30) pg/mL, p=0.078). There were some gender differences apparent, with the following adjusted change between baseline and week 12: CRP (males -3% vs females +17%, p=0.19), IL6 (males +17% vs females +48%, p=0.77), sICAM-1 (males -5% vs females +11%, p=0.07), sVCAM-1 (males +54% vs females +19%, p=0.08) and hunger ratings (males 20% vs females -5%, p=0.18). On balance, males experienced a maintainence or reduction in three inflammatory markers and an improvement in hunger ratings, and therefore appeared to have responded better to the intervention. Compared to those who didn’t adhere, adherent patients maintained weight (mean(SE) change: +0.5(1.6) vs - 0.8(1.2) kg, p=0.052) and fat-free mass (-0.1 (1.6) vs -1.8 (1.8) kg, p=0.045). There was no difference in change between the intervention and control phase for CRP, appetite, nutritional status or dietary intake. The thesis makes a significant contribution to the evidence base for understanding of PEW in dialysis patients. It has advanced knowledge of methods of assessing inflammation and appetite. Retrospective ratings of hunger on a VAS appear to be a valid method of assessing appetite although samples which include patients with very poor appetite are required to confirm this. Supplementation with fish oil appeared to improve subjective appetite and dampen the inflammatory response. The effectiveness of the intervention is influenced by gender and adherence. Males appear to be more responsive to the primary outcome variables than females, and the quality of response is improved with better adherence. These results provide evidence to support future interventions aimed at reducing the effects of PEW in dialysis patients.

Leading indigenous education in a remote location : reflections on teaching to be "proud and deadly"

This thesis is a critical reflection of the author’s time as a Principal of an Indigenous state school from 2003-2004. The purpose is to reassess the impact of her principalship in terms of the staff, students and Community change that affected learning outcomes at the school and to reanalyse to what actions and to whom positive changes could be attributed. This thesis reflects and identifies, in light of the literature, strategies which were effective in enhancing student learning outcomes. The focus of this thesis was the Doongal State School*, its students, staff and facilities. The author will attempt to draw out theoretical frameworks in terms of: (1) what changed educationally in Doongal State School, (2) what seemed to be important in the Principal’s role, (3) the processes that took place, and (4) the effect of being non- Indigenous and a female. Overall, the author undertook this critical reflection in order to understand and embrace educational practices that will (a) lessen the gap between the academic outcomes achieved by Indigenous and non-Indigenous students, and (b) enhance life choices for Indigenous children. The findings indicate that principal leadership is critical for success in Indigenous schools and is the centrepiece of the models developed to explain improvement at Doongal State School. School factors, Principal Leadership factors, Change factors and factors relating to being a non-Indigenous female principal, which, when implemented, will lead to improved educational outcomes for Indigenous students, have evolved as a result of this thesis. Principal Leadership factors were found to be the enablers for the effective implementation of the key components for success.

Substance misuse in patients with schizophrenia : Epidemiology and management

Substance misuse in individuals with schizophrenia is very common, especially in young men, in communities where use is frequent and in people receiving inpatient treatment. Problematic use occurs at very low intake levels, so that most affected people are not physically dependent (with the exception of nicotine). People with schizophrenia and substance misuse have poorer symptomatic and functional outcomes than those with schizophrenia alone. Unless there is routine screening, substance misuse is often missed in assessments. Service systems tend to be separated, with poor inter-communication, and affected patients are often excluded from services because of their comorbidity. However, effective management of these disorders requires a fully integrated approach because of the close inter-relationship of the disorders. Use of atypical antipsychotics may be especially important in this population because of growing evidence (especially on clozapine and risperidone) that nicotine smoking, alcohol misuse and possibly some other substance misuse is reduced. Several pharmacotherapies for substance misuse can be used safely in people with schizophrenia, but the evidence base is small and guidelines for their use are necessarily derived from experience in the general population.

A novella of ideas : how interactive new media art can effectively communicate an indigenous philosophical concept

How interactive new media art can effectively communicate an indigenous philosophical concept. The sophistication and complexity of the philosophical concept concerning relationships between land and people and between people, intrinsic to the laws and customs of Australian Indigenous society, has begun to be communicated and accessed beyond the realm of anthropological and ethnological domains of Western scholarship. The exciting scope and rapid development of new media arts presents an innovative means of creating an interactive relationship with the general Australian public, addressing the urgent need for an understanding of Indigenous Australian concepts of relationship to land, and to each other, absent from Western narratives. The study is framed by an Indigenous concept of place, and relationships between land and people and between people; and explores how this concept can be clearly communicated through interactive new media arts. It involves: a creative project, the development of an interactive new media art project, a website work-in-progress titled site\sight\cite; and an exegesis, a Novella of Ideas, on the origins, influences, objectives, and potential of creative practices and processes engaged in the creative project. Research undertaken for the creative project and exegesis extended my creative practice into the use of interdisciplinary arts, expressly for the expression of philosophical concepts, consolidating 23 years experience in Indigenous community arts development. The creative project and exegesis contributes to an existing body of Indigenous work in a range of areas - including education, the arts and humanities - which bridges old and new society in Australia. In this study, old and new society is defined by the time of the initial production of art and foundations of knowledge, in the country of its origins, in Indigenous Australia dating back at least 40,000 years.

A novel system for the measurement of body shape and construction of seating supports for patients

Patients with severe back deformities can greatly benefit from customized medical seating. Customized medical seating is made by taking measurements of each individual patient and making the seat as per these measurements. The current measuring systems employed by the industry are limited to use in clinics which are generally located only in major population centres. Patients living in remote areas are severely affected by this as the clinics could be far away and inaccessible for these patients. To provide service of customized medical seating requires a new measurement system which is portable so that the system could be transported to the patients in remote areas. The requirements for a new measurement system are analysed to suite the needs of Equipment Technology Services of the Cerebral Palsy League of Queensland. Design for a new measurement system was conceptualised by reviewing systems and technologies in various scientific disciplines. Design for a new system was finalised by optimizing each individual component. The final approach was validated by measuring difficult models and repeating the process to check for process variances. This system has now been adopted for clinical evaluation by ETS Suggestions have been made for further improvements in this new measurement approach.

Influence of UGT1A9 intronic I399C4T polymorphism on SN-38 glucuronidation in Asian cancer patients

Genetic polymorphisms in hepatically expressed UGT1A1 and UGT1A9 contribute to the interindividual variability i-n irinotecan disposition and toxicity. We screened UGT1A1 (UGT1A1*60, g.−3140G>A, UGT1A1*28 and UGT1A1*6) and UGT1A9 (g.−118(T)9>10 and I399C>T) genes for polymorphic variants in the promoter and coding regions, and the genotypic effect of UGT1A9 I399C>T polymorphism on irinotecan disposition in Asian cancer patients was investigated. Blood samples were collected from 45 patients after administration of irinotecan as a 90 min intravenous infusion of 375 mg/m2 once in every 3 weeks. Genotypic–phenotypic correlates showed that cancer patients heterozygous or homozygous for the I399C>T allele had approximately 2-fold lower systemic exposure to SN-38 (P<0.05) and a trend towards a higher relative extent of glucuronidation (REG) of SN-38 (P>0.05). UGT1A1–1A9 diplotype analysis showed that patients harbouring the H1/H2 (TG6GT10T/GG6GT9C) diplotype had 2.4-fold lower systemic exposure to SN-38 glucuronide (SN-38G) compared with patients harbouring the H1/H5 (TG6GT10T/GG6GT10C) diplotype (P=0.025). In conclusion, this in vivo study supports the in vitro findings of Girard et al. and suggests that the UGT1A9 I399C>T variant may be an important glucuronidating allele affecting the pharmacokinetics of SN-38 and SN-38G in Asian cancer patients receiving irinotecan chemotherapy.

Contribution of thickened drinks, food and enteral and parenteral fluids to fluid intake in hospitalised patients with dysphagia

Background Studies amongst older people with acute dysphagic stroke requiring thickened fluids have assessed fluid intakes from combinations of beverage, food, enteral and parenteral sources, but not all sources simultaneously. The study aimed to comprehensively assess total water intake from food, beverages, enteral and parenteral sources amongst dysphagic adult in-patients receiving thickened fluids. Methods Patients requiring thickened fluid following dysphagia diagnosis were recruited consecutively from a tertiary teaching hospital’s medical and neurosurgical wards. Fluid intake from food and beverages was assessed by wastage, direct observation and quantified from enteral and parenteral sources through clinical medical records. Results No patients achieved their calculated fluid requirements unless enteral or parenteral fluids were received. The mean daily fluid intake from food was greater than from beverages whether receiving diet alone (food 807±363mL, food and beverages 370±179mL, p<0.001) or diet with enteral or parenteral fluid support (food 455±408mL, food and beverages 263±232mL, p<0.001). Greater daily fluid intakes occurred when receiving enteral and parenteral fluid in addition to oral dietary intake, irrespective of age group, whether assistance was required, diagnosis and whether stage 3 or stage 2 thickened fluids were required (p<0.05). After enteral and parenteral sources, food provided the most important contribution to daily fluid intakes. Conclusions The greatest contribution to oral fluid intake was from food, not beverages. Designing menus and food services which promote and encourage the enjoyment of fluid dense foods, in contrast to thickened beverages, may present an important way to improve fluid intakes of those with dysphagia. Supplemental enteral or parenteral fluid may be necessary to achieve minimum calculated fluid requirements.

A pilot randomised control trial of general practitioner and exercise physiologist interventions to reduce primary cardiovascular risk in overweight patients [Abstract]

Aims & Rationale/Objectives: With the knowledge that overweight is a major public health concern in Australia, that a multidisciplinary team approach to the management of lifestyle-related conditions is supported, and that the Australian Government recently recognised the role of the exercise physiologist (EP) in reducing the health burden of disease by their inclusion for reimbursement under the Medicare Plus scheme, this study sought to undertake a pilot RCT to compare GP and EP interventions to reduce primary cardiovascular risk in the overweight general practice population. Methods and Measures: Overweight patients recruited by a convenience sample of GPs were randomised into one of three arms: the control group, or the GP or EP intervention group (in which patients received either five GP or five EP consultations over 24 weeks). Patients had baseline, 12- and 24-week measures of body composition and cardio-respiratory fitness, and completed baseline and end-of-study surveys, fasting lipids and glucose. GPs and EPs completed an end-of-study survey. Results:Sixty-seven patients attended the baseline assessment. Overall retention rate was 67%. Patients were generally satisfied with the effectiveness of the interventions and their weight reduction. Favourable trends in BMI, weight, glucose and exercise levels for GP and EP intervention groups and in physical activity levels for all groups Conclusions: This study supports the feasibility of a RCT of GP and EP interventions for decreasing primary cardiovascular risk in the overweight general practice population.

Reconciling Nicci Lane : the 'unspeakable' significance of Australia's first indigenous porn star

This article will explore X-rated representations of Aboriginality in Australian-produced pornographic videos, particularly the image of Australia's first Indigenous porn-star, Nicci Lane. It investigates how pornographic narratives involving 'Aboriginal' characters or motifs are connected to broader embodiments of Aboriginality in popular culture. Drawing a parallel with Australian television drama and mainstream films, the article highlights how contemporary sexualized images of Aboriginal people are intimately tied to a politics of reconciliation. By surveying recent literature on pornography, which describe how certain pornographic narratives engage 'unspoken' community desires, my argument will discuss Nicci Lane's career as a unique development in the history of representations of Aboriginality. Through analysis of Lane’s Arigato Baby (1991), these ‘unspoken’ desires relate to showing Indigenous people in everyday sexual contexts, as romantic partners, friends and lovers. My argument will go on to suggest that, through Nicci Lane's performance and profile, the image of Australia’s first Indigenous porn-star offers the possibility for imagining new kinds of interracial intimacy within the Australian public sphere.